Violation of behavior in dementia

Potentially dangerous for themselves and others are typical for patients with dementia and serve as the primary reason for bringing home nursing care in 50% of cases. The actions of such patients include vagrancy, anxiety, screaming, pugnacism, refusal of treatment, resistance to staff, insomnia and tearfulness. Behavioral disorders that accompany dementia have not been adequately studied.

Opinions about what actions a patient can be attributed to behavioral disorders are largely subjective. Tolerance (which acts of the guardian / caregiver can be tolerant) depends to some extent on the established order of the patient's life, in particular his safety. For example, vagrancy can be acceptable if the patient is in a safe environment (when there are locks and alarms on all doors and gates in the house), but if the patient leaves the shelter or hospital, vagrancy may be unacceptable, because it can disturb other patients or be a nuisance for the activity of a medical institution. Many behavioral disorders (including vagrancy, recurring questions, contact disorders) are less severe for others during the day. Does sunset (exacerbation of behavioral disturbances at sunset and in the early evening time) or the true daily fluctuations of behavior matter is unknown at the present time is unknown. In shelters, 12-14% of patients with dementia have more behavioral disorders in the evening than during the day.

Causes of behavioral disorders in dementia

Behavioral disorders can be the result of functional disorders associated with dementia: a decrease in the ability to control behavior, misinterpretation of visual and auditory signals, a decrease in short-term memory (for example, the patient repeatedly requests a thing that he has already received), a decrease or loss of ability to express one's needs , patients wander because they are lonely, scared or looking for someone or anything).

Patients with dementia often poorly adapt to the established mode of stay in the institution. In many elderly patients with dementia, behavioral disorders occur or are aggravated when they move to conditions more restrictive to their behavior.

Somatic problems (for example, pain, difficulty breathing, urinary retention, constipation, improper treatment) can lead to an exacerbation of behavioral disorders in part because patients can not adequately communicate with others. Somatic problems can lead to the development of delirium, and delirium, superimposed on pre-existing dementia, can exacerbate behavioral disorders.

[1], [2], [3], [4], [5], [6]

Symptoms of behavioral disorders in dementia

The best approach is the classification and specific characteristics of behavioral disorders, rather than designating them as "behavioral agitation", a term so common that it makes it less useful. Specific behavioral aspects, events associated with it (eg food, toilet, medication, visits) and the time of their onset and termination should be recorded, which helps in identifying changes in the overall picture of the patient's behavior or in assessing their severity and facilitates the planning of the treatment strategy. If the behavior has changed, a physical examination should be performed to exclude somatic disorders and improper handling of the patient, at the same time, factors of environmental changes (including the change of the nurse) should be taken into account, since they may be the primary cause of changes in the behavior of the patient, and not true changes in his condition.

Psychotic behavior must be identified, because its treatment is different. The presence of manias and hallucinations indicates a psychosis. Mania and hallucinations must be distinguished from disorientation, anxiety and misunderstanding, which are common for patients with dementia. Mania without paranoia can be confused with disorientation, while mania is usually fixed (for example, a shelter, repeating, the patient calls a prison), and disorientation varies (for example, the patient calls the shelter a prison, then a restaurant, then a home).

Treatment of behavioral disorders in dementia

Approaches to the treatment of behavioral disorders in dementia are contradictory and have not been fully studied to the present. Supportive measures are preferred, but drug therapy is also used.

Activities affecting the environment

The environment of the patient should be safe and flexible enough to adapt to his behavior, excluding the possibility of damage. Signs that a patient needs help should be encouraged to equip doors with locks or an alarm system, which can help insure a patient who is prone to vagrancy. The flexibility of sleep and wakefulness, the organization of a place to sleep can help patients with insomnia. The activities used to treat dementia usually also help to minimize behavioral disorders: providing time and place orientation, explaining the need for custody before it starts, encouraging physical activity. If the organization can not provide the appropriate environment for the individual patient, it is necessary to transfer it to the place where drug therapy is preferred.

[7], [8], [9]

Carer Support

Learning how dementia leads to behavioral disorders and how to respond to behavioral disorders can help family members and other caregivers provide care and better cope with patients. Learning how to manage a stressful situation, which can be significant, is necessary.

[10]

Medicinal products

Drug therapy is used when other approaches are ineffective and the use of medications is necessary for patient safety reasons. The need to continue drug therapy should be evaluated on a monthly basis. The choice of medicines should be made in order to correct the most persistent behavioral disorders. Antidepressants are preferred from the group of selective serotonin reuptake inhibitors, and should be given only to patients with symptoms of depression.

Antipsychotics are often used despite the fact that their effectiveness is shown only in patients with psychotic disorders. In other patients (without psychotic complications), one can hardly expect success, and there is a possibility of the development of side effects, especially extrapyramidal disorders. Late (delayed) dyskinesia or late dystonia may develop; often these disorders do not decrease even with a reduced dose or with complete withdrawal of the drug.

The choice of an antipsychotic depends on its relative toxicity. Conventional antipsychotics such as haloperidol have a relatively low sedative effect and have a less pronounced anticholinergic effect, but more often cause extrapyramidal disorders; thioridazine and thiotixen to a lesser extent promote the development of extrapyramidal symptoms, but have a more pronounced sedative effect and more significant anticholinergic effects than haloperidol. Second-generation antipsychotics (atypical antipsychotics) (for example, olanzapine, risperidone) have minimal anticholinergic effects and cause fewer extrapyramidal symptoms than commonly used antipsychotics, but the use of these drugs for a long time may be associated with an increased risk of hyperglycemia and overall mortality. In elderly patients with dementia-related psychosis, the risk of cerebrovascular disorders also increases with the use of these drugs.

If antipsychotics are used, they should be given at low dosages (for example, olanzapine 2.5-15 mg orally once a day, risperidone 0.5-3 mg orally every 12 hours, haloperidol 0.5-1.0 mg orally , intravenously or intramuscularly) and for a short period.

Anticonvulsants - carbamazepine, valproate, gabapentin and lamotrigine can be used to control episodes of uncontrolled agitation. There is evidence that beta-blockers (eg, propranolol in the initial dosage of 10 mg with a gradual dose increase to 40 mg twice daily) are useful in some patients with psychomotor agitation. In this case, patients should be monitored for arterial hypotension, bradycardia and depression.

Sedatives (including short-acting benzodiazepines) are sometimes used for a short period of time to alleviate anxiety, but they can not be recommended for long-term use.